Classic Readings in Psychiatry and Related Fields
A study group of the psychiatry residents at UCLA-NPI

Classics Club is an opportunity to read and discuss one or two selections each session from classic papers and authors in psychiatry and related fields, with an emphasis on seminal papers in psychoanalysis. We will also read some classic papers from academic psychology, cognitive science, and anthropology, as they may illuminate or critique psychodynamic concepts.

We have been lucky during the past year to have clinical and theoretical insights during the lunches from psychoanalytically trained psychiatrists Dr. David Coffey, Dr. Angel Cienfuegos, Dr. David Leviadin, and from our program director Dr. James Spar. We look forward to hearing from other faculty during the coming year.

The journal club began during the 2008-2009 academic year and largely focused on readings that seemed fairly digestible on their own, applicable to situations that PGY2 and PGY3 residents encounter frequently, and not employing so much of the metaphor or terminology that one can get bogged down in. In practice, this meant several articles from George Vaillant and D. W. Winnicott, as well as Sigmund Freud's “Mourning and Melancholia” and an essay by Nancy Chodorow on female development. This year (2009-2010) we are trying to work through Freud's three major theoretical models (topographic, structural, and psychosexual development), with some applications to therapy in the spring. Next year (2010-2011) we plan to cover different aspects of object relations, one of the dominant strands of psychodynamic theory in psychiatry since the middle of the 20th century.

We are also trying to generate on online annotated bibliography for those who want to read further on their own. For residents interested in additional readings on their own, the following are good introductions to psychoanalytic theory:

Galatzer-Levy, Robert M. and Bertram J Cohler. (1994) The essential other: a developmental psychology of the self. Cambridge, MA: Harvard University Press.

Gedo, John, and Arnold Goldberg. (1973) Models of the mind: a psychoanalytic theory. Chicago: University of Chicago.

The reading group originally met the second Friday of the month during regular resident lunches. It now meets the second Tuesday of the month, during the resident lunch following Grand Rounds at UCLA-NPI. Readings are normally distributed beforehand, along with an email briefly outlining the main concepts and their theoretical and historical context.

Please note: future readings are subject to change. This syllabus is a work in progress and responds both to the interests of the residents and suggestions from our faculty discussants.

Readings for Academic Year 2008-2009
8/08/2008: Ego Mechanisms of Defense

Vaillant, George. (1992) “The place of defense mechanisms on diagnostic formulation and in modern clinical practice.” In: George Vaillant, ed. Ego Mechanisms of Defense: a guide for clinicians and researchers. Washington, DC: American Psychiatric Press. Pp 29-42.

11/14/2008: Discovering Selves and Others: D. W. Winnicott

— (1953) “The use of an object.” International Journal of Psycho-analysis, 50: 711-716.

Modell, Arnold H. (1985) “The works of Winnicott and the evolution of his thought.” Journal of the American Psychoanalytic Association, 33 (supp): 113-137.

This is the first of several readings planned on Donald W. Winnicott and his works. Initially trained as a pediatrician in Britain, Winnicott was one of the most influential of the Object Relations theorists, a prolific and provocative writer but not always one of the most transparent. He is famous for saying "there is no such thing as 'an infant'", emphasizing the intensely social nature of the infant-mother dyad and the fact that no human infant exists in a social vacuum. Though he did not develop a systematic theory of human development or psychic function as such, his work inspired many schools of psychologists and psychiatrists interested in child development and interpersonal relations. Many of his concepts have now become standard in these fields, so common-sensical that we tend to forget their origins. He is also perhaps the best known of the so-called "Middle Group" of British psychoanalysts, between Melanie Klein and her adherents on the one side and and the Ego Psychology of Anna Freud and her associates on the other.

In the readings for this session, Winnicott discusses the use of the teddy bear as a transitional object to establish a concept of self, explores the child's sense of play, and describes the "good-enough mother", a core idea in dealing with many personality disorders and in thinking of the therapeutic experience as re-parenting. The third article is a chapter from Arnold Modell outlining Winnicott in general.

12/12/2008: Perspectives on Female Development

Faculty discussant: Dr. David Coffey

Chodorow, Nancy J. (1989) “Being and doing: a cross-cultural examination of the socialization of males and females.” In: Feminism and Psychoanalytic Theory. New Haven, CT: Yale University Press. Pp: 23-44.

In this essay, Freud lays out some of the classic observations on the processes of repression, resistance, and acting out which occur in the context of therapy, and suggests why patients may appear to get worse in the short term as they begin the longer-term process of getting better.

4/10/2009: George Vaillant - Dealing with Primitive Defenses 1

Faculty discussant: Dr. David Coffey

Vaillant, George E. (1975) “Sociopathy as a human process. A viewpoint.” Archives of General Psychiatry 32(2):178-83.

5/08/2009: George Vaillant - Dealing with Primitive Defenses 2

Faculty discussant: Dr. David Coffey

Vaillant, George E. (1992) “The beginning of wisdom is never calling a patient a borderline; or, The clinical management of immature defenses in the treatment of individuals with personality disorders.” Journal of Psychotherapy Practice and Research 1:117-134.

We will again be reading a selection from George Vaillant. This paper is one of the most-recommended papers on syllabi for C/L psychiatry and frequently cited in discussions of clinical management of personality disorders. The paper describes most of the major types of primitive and maladaptive coping mechanisms, how they manifest in therapy or other clinical practice, and suggests strategies for dealing with them.

The case that started it all: Sigmund Freud and Josef Breuer's early patient “Anna O.” (aka Bertha Pappenheim), was a woman with hysterical conversion symptoms. Her treatment, partly with hypnosis and partly with free association, sparked Freud's conception of repression as well as the primary technique of psychoanalytic treatment--free association--as a way of getting behind repression. This led in time to the development of early psychoanalytic method.

The earliest of Freud's models for how the mind works, the topographic model divides the mind into parts that are Conscious (Cs - things of which one is aware), the Preconscious (Pcs - things that you are not thinking of now, but that can be easily brought into consciousness, like remembering your dental appointment next week or what you had for breakfast), and the Unconscious (Ucs - note, not "subconscious" - made up of things that have been repressed or otherwise not allowed into consciousness). These lectures are part of a series of five that were delivered at Clark University in Worcester, MA, in 1909. (The full lectures are available on line at http://www.rasch.org/over.htm) In these lectures, he outlines his theory of mental functioning and psychopathology as he understood it at the time. The first lecture, which we are skipping, largely recapitulates the material from the case of Anna O., which we read last month. The second and third lectures continue with his discussion of conflicts, hysteria, psychoanalytic method, repression, and slips of the tongue and other unconsciously motivated "accidents"(parapraxes).

8/14/2009: Attachment - John Bowlby, Mary D. Ainsworth, & Mary Main

Main, Mary. (1996) “Introduction to the special section on attachment and psychopathology: 2. Overview of the field of attachment.” Journal of Consult Clinical Psychology 64(2):237-43.

While our overall goal during the first half of this year is to cover Freud's three major theoretical models (topographic, structural, and psychosexual development), we will be taking a brief detour into attachment theory over the next two months in preparation for our illustrious guest speaker in September.
Dr. Anthony Bateman is a psychiatrist at University College London who will be speaking to us during the third week of September. Together with Dr. Peter Fonagy, he has developed one of the main therapeutic approaches to treating borderline personality disorder and related conditions. Their approach, Mentalization-Based Psychotherapy, derives in part from attachment theory.

Attachment refers to proposed psychological and neurological systems in human beings that mediate particular social relationships, especially the parent-child relationship and possibly romantic relationships. These appear to develop during crucial periods in early childhood and affect aspects of temperament, emotional regulation, and interpersonal relations throughout life. The concept was developed initially by John Bowlby, arising in part from and in part in reaction to psychoanalysts in London such as Melanie Klein and Donald Winnicott.
For the next two sessions, we will read first an overview of the history and concepts of attachment theory, and then an article by Bateman and Fonagy describing their (evidence-based) therapy and how it grows out of attachment theory and related offshoots of psychoanalysis.
For the August session then, we will focus on an article by Bowlby and his colleague Mary D. S. Ainsworth, who developed the main technique for assessing attachment in infants, the Strange Situation.

One of the difficulties of reading about attachment theory is that most of it is either in very long books (Attachment and Loss, 3 vols, at 400-plus pages per book documenting the theory, clinical observations, and experiments with animals and humans), or in very technical ethology papers by researchers such as Harry Harlowe, whose work with baby Rhesus macacques interacting with wire vs cloth "mothers" you probably remember from human development or intro psychology courses. This article, in constrast, shows Bowlby and Ainsworth talking about their initial inspirations and challenges and places their theoretical insights in a historical context.
The second paper is more for further reading for those who are interested. Mary Main is an American psychologist who explicitly extended attachment theory to adults, developing attachment style assessment instruments and carrying out further empirical research.

9/11/2009: Mentalization and Attachment-based therapies: the work of Anthony Bateman & Peter Fonagy

And for further reading, an interesting commentary on a case of borderline personality disorder by the proponents of three different (though overlapping) theoretical models: Anthony Bateman, John Gunderson, and Otto Kernberg: the case of "Ellen": Gunderson, John G., Anthony Bateman, and Otto Kernberg. (2007) “Alternative perspectives on psychodynamic psychotherapy of Borderline Personality Disorder: the case of 'Ellen'.” American Journal of Psychiatry 164:1333-1339.

In his earlier writings, Freud had assumed/posited that a major driver and motivator in the psyche is the desire to avoid pain/anxiety/conflict. He also implied some importance for a positive desire of pleasurable things. In this essay, he begins to work out two major driving factors, also ways of engaging with the world, that motivate behavior. The pleasure/unpleasure principle is the desire to achieve or reexperience pleasurable things while avoiding unpleasurable things. This is associated with a "childlike" or infantile disregard of reality, including consequences for oneself (if I eat chocolate and don't exercise, I'll get fat), consequences for others (if I take chocolate from my baby sister, she'll be unhappy and cry), physical reality (the chocolate is in the store and the store is closed and locked until tomorrow morning), and social reality (if I eat the chocolate before dinner, I'll get in trouble). Because the pleasure/unpleasure principle is childlike and ignores reality, its most basic mechanism for avoiding unpleasure (aside from physically avoiding it) is to deny it--the motive for repression. Alternatively, the mind can present itself with hallucinatory wish-fulfillments, pretending to itself that the world is as it wants. (This wish-fulfilling phantasy later becomes a major concept in the work of Melanie Klein.)

However, ignoring reality is not sustainable, and in time causes its own share of unpleasure and missed opportunities for pleasure. The reality principle develops partly as the psyche seeks to protect itself from the unpleasantness of butting up against physical and social reality; in developing a reality-testing function, becomes the mediating factor that seeks pragmatic compromise with the real world.

A significant feature in this, which allows us to understand much of the implicit framework of later writings, is Freud's use of contemporary homeostatic models from physiology. He postulates that the ego seeks ultimately to reduce tensions, to discharge emotional energy, and to avoid excitement of any kind (seeing hunger as seeking satisfaction of a deficiency state, and sexual desire to some degree as the discharge of a buildup of sexual energy). These homeostatic principles have since been heavily modified, to say the least, and most behavioral researchers currently do not explain motivation as primarily seeking drive reduction in these terms. However, understanding this aspect of drive theory is crucial to be able to translate much of later Freud and his mid-century successors into modern psychological terms.

A reminder of terminology: cathexis is the binding of psychic/emotional energy to an object (an internal representation of something in the world, usually another person or aspect of a person, but potentially also an idea).

This essay is part of a transition from Freud's early topographic model to his later structural model. The early division of the psyche into Conscious, Preconscious (essentially a holding area for the Conscious, more of a distinction between working memory/awareness and declarative memory/that which can readily be called into awareness), and Unconscious (that which is repressed or has never been allowed into consciousness), gave way to his structural a model, in which several agents/modules/functions in the psyche operate on different principles. The Id (the It) would be identified with the pleasure/unpleasure principle and its primary process, the Ego (the I) with the reality principle, and the Super-ego (the Above-me) comprising the internalized values (positive and negative) of one's parents and the larger society as well as one's aspirations (Ego-Ideal).

12/11/2009: Ego Psychology - Heinz Hartmann

Faculty discussant: Dr. Joshua Pretsky

Hartmann, Heinz. (1950) “Comments on the psychoanalytic theory of the Ego.” Psychoanalytic Study of the Child, 5:74-96.

Heinz Hartmann (1894-1970) was an Austrian-born psychiatrist and one of the main figures in early Ego Psychology (along with Anna Freud, Rene Spitz, Margaret Mahler, and Erik Erikson, many of whom published in the journal Psychoanalytic Study of the Child). Ego Psychology focuses on ego functions of reality testing, adaptation, defense mechanisms, etc. This reading discusses a number of Freud's and others' thinking on ego and ego functions. It also displays some of the limitations of metaphors of the mind from the mid-20th century, including a preoccupation with mental “energy” which seems less relevant in light of more recent cognitive models of the mind as information processor.

*1/15/2010: On Narcissicism

Faculty discussant: Dr. Angel Cienfuegos
* Please note that we will be meeting on the 3rd Friday this month, because of the New Year's holiday.

The first paper returns to Winnicott and develops parallels between the role of a mother towards a child and of a therapist towards a patient, examining the sometimes hostile feelings that emerge in both relationships. He argues that becoming aware of and accepting these feelings for what they are can one effectively help the patient.

The second paper is a classic in consult-liaison psychiatry and is one of the most frequently referenced papers in resident syllabi. It describes four particularly challenging types of patients seen in both psychiatric and medical settings, and suggests ways of dealing with them, and of the physician's feelings towards them.

6/11/2010: Feminist Perspectives and Critiques: Karen Horney

Karen Horney (1885-1952) was a psychoanalytically trained psychiatrist who made significant contributions to the psychoanalytic understanding of women's experience. In this essay, she critiques Freud's model of psychosexual development, in particular the Oedipus complex and how it applies to women. Freud's thoughts on gender are rather peculiar, when one considers that most of his patients were female but most of his developmental models assume the perspective of a male subject. Horney challenges this and also discusses a number of psychoanalytic positions and observations on common concerns of women patients in clinical practice.

Readings for Academic Year 2010-2011

Please Note: starting with the July 6 session, journal club will change to the second Tuesday of each month.

Now that we have surveyed some of the founding principles of psychoanalytic thought, our goal over the course of this academic year is to look more at one of the main streams of contemporary psychodynamic theory: Object Relations. Sigmund Freud's main theories focused on drives and their conflicts--the desire of the infant for food and (erotic) pleasure, sole possession of the mother, and fantasies of grandiosity and omnipotence. These came into conflict with both the (moral) demands of the parents, representing society and social mores, and with the brute facts of reality (mom can't always be there to meet our needs). Freud did acknowledge the importance of both actual and imagined relationships (most notably in his account of depression arising from the loss of an ambivalently loved object). However, his main focus remained on drives and unconscious conflicts, particularly the individual's resolution or failure to adequately resolve the Oedipus conflict, in which one reconciles onself to not having sole access to the mother and instead identifies with the father and social mores. WW II forced many prominent analysts to relocate to Britain or the US, where psychoanalysis developed in new directions. In London, Freud's daughter Anna and her rival Melanie Klein (student of Freud's Hungarian colleague Sandor Ferenczi) both tested and expanded Freud's hypotheses about early development with actual observation and analysis of troubled children. Anna Freud emphasized the role of defenses or coping mechanisms, leading to a school known as Ego Psychology (and later Self Psychology in the US, as developed by Kohut). Klein emphasized the importance of pre-Oedipal needs for love and object constancy and the role of relationships with others (or at least with introjected representations of others). Between these two, but in ways more theoretically linked to Klein's ideas, developed the so-called Middle School of theorists interested in object relations: Ronald Fairbairn, Harry Guntrip, Donald Winnicott, Alfred Bion, Michael Balint, and others, as well as the Kleinian-meets-ethology research program on attachment theory of John Bowlby and Mary Salter Ainsworth.

Erik Erikson (1902-1994) was a Danish-German-American psychoanalyst, and one of a handful of important psychoanalytic thinkers whose background was neither in medicine nor psychology. Though often regarded as part of the other main stream of modern psychoanalytic thinking, Ego Psychology, in many ways Erikson’s work dovetails with the concerns of Object Relations. In this selection, Erikson re-envisions and expands Freud's developmental stages. He proposes a series of devlopmental, interpersonal, and existential tasks that all human beings need to face and master over the life course.

Mélanie Klein (1882-1960) was an Austrian-born psychoanalyst who specialized in the analysis of fairly disturbed children. Like Erikson later, she did not have formal training in medicine or psychology, but she had been analyzed and trained in Budapest by Sandor Ferenczi and then in Berlin by Karl Abraham. She moved to London during the Second World War, where she became an influential figure, eventually splitting the British psychoanalytic establishment between her followers, those of Anna Freud, and the Middle School. She was the first to analyze young children, and along with Anna Freud, one of the first to test psychoanalytic ideas against direct observation of children rather than extrapolating from the recall and fantasies of adults in analysis. These two papers discuss many of her ideas about the challenges of emotional and ego development in infancy, including the importance of pre-Oedipal conflicts and needs for understanding adults with severe personality disorders.

10/08/2010: Mélanie Klein on primitive defenses 2

Faculty discussant: Dr. Shirah Vollmer

Resident discussant: Dr. David Willison

Klein, Mélanie. (1952) “Some theoretical conclusions regarding the emotional life of the infant.” In: M. Klein, Envy and gratitude and other works 1946-1963. [1975] Hogarth Press and the Institute of Psycho-Analysis. Pp. 61-93.

For further reading: Segal, Hanna (1980) Introduction to the work of Melanie Klein, 2nd ed. New York: Basic Books, pp.25-38 & 67-81.

2/11/2011: Margaret Mahler: Symbiosis and Individuation

Margaret S. Mahler. (1967) “On Human Symbiosis and the Vicissitudes of Individuation.” Journal of the American Psychoanalytic Association, 15: 740-763

Though she is often considered more part of the intellectual tradition of Ego Psychology, Margaret Mahler's (1897-1985) work with infant and child development shares strong conceptual similarities with Object Relations theorists. In particular, her "average expectable mother" resembles Winnicott's idea of the "good-enough mother" and "optimal frustration". In this essay, she considers the challenges faced by the infant in negotiating a self distinct from its mother but in relation to her.

Another American, Irving Hallowell (1892-1974) was one of the pioneers of psychological anthropology. A professor of anthropology at University of Pennsylvania who conducted extensive fieldwork among a number of Native American groups in the early 20th century, he trained as a lay analyst and applied analytic ideas in his understanding of non-western peoples and cultures. He developed some of the key concepts in understanding the role of cultural variation in psychodynamic processes. In this article he demonstrates the importance of considering projection, phantasy, myth, religion, and cultural categories in understanding how persons relate to others. In particular, he argues that Ojibwa (Native Americans from the Upper Midwest) often participate in meaningful relationships with beings we would consider spirits, and opens up the question of spiritual or religious beliefs in object relations.

Ronald Fairbairn (1889-1964) was a Scottish psychiatrist and analyst. Other than a brief stint in the army during WW I, Fairbarn spent most of his career in the relative academic isolation of Edinburgh. There he developed Klein's theories further, though he took issue with her basically Freudian emphasis on drives. In particular, he proposed that the libido is more object-seeking than pleasure-seeking (anticipating later findings of the attachment researchers). He was a mentor to the minister-turned-analyst Harry Guntrip, and much of his influence on the Middle School of British psychoanalysis came through Guntrip's interpretations and expansions of his ideas.

Harry Stack Sullivan (1892-1949) was an American psychiatrist who read widely in psychoanalysis, social psychology, and social anthropology. Though not strictly part of the Object Relations school, his interpersonal approach shares many common elements in its emphasis on interpersonal relationships and the social context. Sullivan's ideas heavily influenced the practice of American psychodynamic psychotherapy, perhaps even more outside psychoanalysis and psychiatry proper than within them. Interpersonal Psychotherapy (IPT) derives in large part from his ideas as interpreted by his students.

6/10/2011: The Process of Psychotherapy: The Holding Environment

Faculty discussant: TBA

Resident discussant: Dr. Melanie Asbury

Modell, Arnold H. (1965) “On having the right to a life.” In: A. H. Modell (1984) Psychoanalysis in a New Context. New York: International Universities Press. Chap 4. Originally published (1965) International Journal of Psycho-analysis, 46: 323-331.

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